ORIGINAL ARTICLE

Emotional Abuse in Childhood Is a Differential Factor

for the Development of Depression in Adults
Camila Maria Severi Martins, MPhil,* Cristiane Von Werne Baes, MD, MPhil,*
Sandra Marcia de Carvalho Tofoli, MPhil,* and Mario Francisco Juruena, MD, PhD*

Abstract: We evaluate the association between subtypes of early life stress

(ELS; sexual abuse, physical abuse, emotional abuse, physical neglect, and emotional neglect) and psychiatric disorders in adults. The sample was composed of
81 adult psychiatric patients treated at the Day Hospital Unit in Brazil. The patients were assessed using the Mini International Neuropsychiatric Interview according to diagnostic criteria of the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition. The presence of ELS was confirmed by the Childhood
Trauma Questionnaire, which investigates abuse and neglect subtypes. The patients were also evaluated for the severity of psychiatric symptoms through
self-report questionnaires. A total of 71.6% of the patients experienced some type
of severe ELS compared with 28.4% of the patients without ELS. Of these,
55.5% reported having experienced emotional abuse; 48.1%, physical neglect;
45.7%, emotional neglect; 39.5%, physical abuse; and 27.2%, sexual abuse.
Our data showed that, among the ELS subtypes, emotional abuse was positively
associated with psychopathology in adults, particularly with mood disorders (p <
0.05). The patients with a history of emotional abuse had higher severity scores in
all symptoms, such as depression, hopelessness, suicidal ideation, anxiety, and
impulsivity. These data demonstrate the impact of ELS, especially in cases of
emotional abuse, as a trigger for psychiatric disorders and indicate that the severity of ELS is associated with severity of psychiatric symptoms. Therefore, further
studies are needed to assess the importance of emotional abuse as a risk factor of
severe psychopathology in adults.
Key Words: Early life stress, emotional abuse, psychiatric disorders,
depression, psychiatric symptoms
(J Nerv Ment Dis 2014;202: 774782)

urrent literature has demonstrated significant associations between

traumatic events occurring in childhood and adolescence, called
early life stress (ELS), with unfavorable outcomes for the individual's
health (Butchart, 2006; Bernstein et al., 2003). The effects of ELS negatively influence child development, affecting all spheres of an individual's
life: behavioral, emotional, social, cognitive, and physical (Mclaughlin
et al., 2010).
In Brazil, from 1980 to 2000, a total of 2 million people died as
a result of situations of violence. From 1999 to 2007, a total of 159,754
children were victims of domestic violence. Moreover, situations of
physical abuse are the primary cause of death in the age group from 5
to 19 years old and the second leading cause among children from 1
to 4 years old (Pires and Miyazaki, 2005). These data show some of
the reality facts, with only sparse records of individual services that
do not reveal the true extent of the problem (Carvalho et al., 2010;
Ferreira and Azambuja, 2011).
*Stress and Affective Disorders Programme, Department of Neurosciences and Behaviour University of Sao Paulo, Brazil; and Centre for Affective Disorders, Psychological Medicine, King's College London, United Kingdom.
Send reprint requests to Mario Francisco Juruena, MD, PhD, Saude Mental (Mental
Health), University of Sao Paulo, Av. Tenente Catao Roxo,
2650 Ribeiro Preto, Sao Paulo, Brazil, CEP: 14051-140.
E-mail: juruena@fmrp.usp.br.
Copyright 2014 by Lippincott Williams & Wilkins
ISSN: 0022-3018/14/202110774
DOI: 10.1097/NMD.0000000000000202

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Concerning global statistics, in 1997, the World Health Organization (WHO) revealed that, considering all countries, 1 in every
5000 children die per year as a result of physical abuse. Another survey
conducted in 1999 showed that 20% of women and 5% to 10% of
men were sexually abused in childhood. Worldwide, the prevalence
of different forms of sexual abuse among children and adolescents
reaches 73 million (7%) among boys and 150 million (14%) among
girls (Hatzenberger et al., 2012). Prevalence of physical abuse ranges
from 4% to 16%, whereas prevalence of neglect or emotional abuse
reaches 10% in high-income countries (Norman et al., 2012).
Furthermore, in 2011, the National Child Abuse and Neglect
Data System of the Children's Bureau, a service protecting American
children and adolescents, conducted a research to identify the profile
of children who were victims of abuse. According to statistical data,
most of the children were white, and more than 25% were 2 years old
or younger. Four fifths of the victims were maltreated by a parent,
17.6 % were physically abused, and 9.1% were sexually abused (Child
Maltreatment Reports).
Children and adolescents exposed to ELS experience serious
consequences in their biopsychosocial constitution. The literature
shows that, during early childhood and adolescence, important brain
structures are being formed, so the negative consequences of traumatic
events are lasting and can remain during the life of the children (Teicher,
2002; Valente, 2011). These children and adolescents may experience
short- to long-term losses, including damage to health in general (fractures, lacerations, brain injuries) and mental health problems (anxiety;
depression; social isolation; suicidal ideation and suicide attempts; substance abuse; conduct disorder; delinquency; and more specifically,
symptoms of posttraumatic stress disorder, such as numbness, chronic
anxiety, helplessness, low self-esteem, and sleep and/or nutrition disturbances) at the entrance to adulthood (Koss et al., 2003; Saffioti, 1997;
Williams, 2002). Other consequences of ELS are related to cognitive
developmental delay, intellectual deficit and school failure, as well as
violence and crime in adolescence (Heim and Nemeroff, 2001;
Mclaughlin et al., 2010; Neigh et al., 2009; Vitolo et al., 2005).
Many epidemiological studies have documented significant associations between ELS and psychiatric disorders in adulthood
(Collishaw et al., 2007; Edwards et al., 2003; Kessler et al., 1997; Mullen et al., 1996). In addition to this, research today shows that more than
30% of the adult psychiatric disorders are directly associated with the
occurrence of ELS, revealing that such experiences have a cumulative
impact on mental health. Furthermore, these studies demonstrate that
ELS may adversely affect a child's development, triggering severe and
disabling psychiatric disorders in adulthood, such as depression (Benjet
et al., 2010; Gibb et al., 2003; Mclaughlin et al., 2010).
The psychological consequences may acutely affect a childs
mental health for entry into adulthood (Aded et al., 2006; Brewerton,
2007). Mello et al. (2009) emphasize that children who have been
through ELS situations have a moderately increased risk for developing
depression in adolescence and adulthood. Approximately a quarter of
abused children fill the criteria for depression when they reach the end
of the second decade of age, representing, then, a substantial public
health problem. Nanni et al. (2012) also found that exposure to ELS doubles the risk for depression recurrence. In this sense, researchers point

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The Journal of Nervous and Mental Disease Volume 202, Number 11, November 2014

out that approximately 60% of cases of depressive episodes are preceded by the occurrence of stressors, especially of psychosocial origin,
so the influence of genetic factors in the development of depression
could be due to an increased sensitivity to stressful events (Baes et al.,
2014; Mello et al., 2009).
In the same direction, occurrence and severity of ELS increase
three times the risk for developing depression in adulthood, according
to a study presented by Wise et al. (2001). Similar data were found in
a recent systematic review conducted by Martins et al. (2011), revealing
that the severity of ELS is associated with the severity of depression and
also that ELS subtypes are important risk factors of depression in
adults. Gibb et al. (2003) have also shown an association between
ELS subtypes, specifically emotional abuse, and increased depression
symptoms in adulthood. Other studies suggest an increase in suicidal
ideation in adulthood in depressed patients with ELS (Briere and Runtz,
1988; Mullen et al., 1996; Tunnard et al., 2014). Surveys also show the
association between emotional abuse and physical abuse with schizophrenia in adulthood (Holowka et al., 2003; Rubino et al., 2009),
whereas the presence of abuse increases the risk for psychosis
(Bebbington et al., 2004; Conus et al., 2010; Tunnard et al., 2014).
Regarding negligence, studies have shown an association with
different psychopathologies, such as the following: physical and emotional neglect are associated with psychotic disorders (Heins et al.,
2011, Uok and Bikmaz, 2007), physical neglect is associated with
personality disorders (Laporte et al., 2011), and emotional neglect is
associated with depressive and anxiety disorders (Hovens et al.,
2010). In this same direction, Carr et al. (2013) published a recent review and found that different subtypes of ELS are associated with several psychiatric disorders; that is, physical abuse, sexual abuse, and
unspecified neglect are associated with mood disorders and anxiety disorders, and emotional abuse is associated with personality disorders
and schizophrenia.
In addition, researchers have identified important considerations
regarding the association between ELS subtypes and therapeutic response of depressive patients. Douglas and Porter (2012) demonstrated
that the severity of ELS subtypes is significantly correlated with the reduction of the worst clinical status, suggesting that ELS subtypes are
detrimental to the successful treatment of severe depression. Kaplan
and Klinetob (2000) found that emotional abuse and parental overprotection are associated with a negative response to antidepressants in patients with moderate-to-severe depression. Although scientific evidence
suggests the existence of association between ELS and psychiatric disorders, more research is needed to confirm it. Thus, the present study
aimed to replicate and extend these findings, evaluating the association
between occurrence and severity of ELS and psychiatric disorders in
adult patients.

METHODS
Study Design
This is a cross-sectional study from a quantitative and qualitative
evaluation of the life history and psychiatric diagnosis of patients
treated at the Day Hospital Unit of General Clinical Hospital. The study
was approved by the Research Ethics Committee of General Clinical
Hospital, Faculty of Medicine of Ribeirao Preto, University of
Sao Paulo.

Participants
The sample was composed of 81 adult psychiatric patients,
treated at the Day Hospital Unit of General Clinical Hospital. The inclusion criteria for this study were as follows: having a psychiatric diagnosis confirmed according to the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994), being followed up at the Day Hospital Unit
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Emotional Abuse and Depression

of the General Clinical Hospital, and aged from 18 to 65 years. We excluded patients with mental disorders caused by a general medical condition or resulting from direct physiological effect of a substance,
substance abuse, or substance dependence. Patients with mental retardation, cognitive deficits, as well as neurological progressive and degenerative diseases and in an acute psychotic episode that could
impair the comprehension of the assessment instruments adopted in
the study were also excluded. Patients were clinically assessed by two
senior psychiatrists (M. F. J., C. V. W. B.) and excluded if they met
any exclusion criteria. After complete study description to the subjects,
their comprehension, and agreement, signed written informed consent
was obtained.
The sample was divided into two groups based on positive history of ELS according to the Childhood Trauma Questionnaire (CTQ;
Bernstein et al., 1994). The first group included those with ELS (with
ELS), and the second included those without ELS (without ELS). We
included in the group of patients with ELS those with moderate and severe scores in at least one of the five ELS subtypes according to
the CTQ.

Instruments and Procedure

The participants were informed that the purpose of the study was
to investigate the association between ELS and psychiatric disorders in
adult life. Later, signed written informed conent was obtained from all
patients, and the questionnaires included in this study were applied.

Demographic and Clinical Data Measures

Clinical and sociodemographic characteristics, such as age, gender, ethnicity, religious practice, family history of psychiatric disorder,
and suicide attempt, were obtained through administration of a
sociodemographic questionnaire developed by the researchers.

Psychiatric Diagnosis Measures

The assessment of psychiatric diagnosis was conducted using
the Mini International Neuropsychiatric Interview (MINI; Sheehan
et al., 1998), the version in Portuguese translated and adapted by
Amorim (2000). The MINI is a brief structured interview designed to
assess criteria for most psychiatric disorders classified in the DSM-IV
and the ICD-10. There is a version called MINI PLUS, intended for assessment of main psychiatric diagnoses throughout life, in clinical and
research psychiatry, and systematically explores all the criteria for inclusion, exclusion, and chronology (onset and duration of the disorder,
number of episodes; Amorim, 2000). All subjects were interviewed by
two senior psychiatrists (M. F. J., C. V. W. B.) trained and certified to use
the standardized interviews. The interviewers had long-standing experience in administration of the standardized interviews.
The evaluation of personality disorders was performed through
the Structured Clinical Interview for DSM-IV Axis II Disorders
(SCID-II; Spitzer et al., 1990). The SCID-II is a self-assessment
semistructured interview, based on axis II criteria of DSM-IV-TR, for
assessing personality disorders (APA, 1989). The version in Portuguese
was translated and adapted by Del-Ben et al. (2001).

ELS Measures
ELS was assessed using the CTQ (Bernstein et al., 1994). The
CTQ is a retrospective self-report questionnaire that investigates history
of abuse (sexual, emotional, physical) and neglect (emotional, physical)
during childhood and can be applied to adolescents (from 12 years old)
and adults, in which the responder assigns values of frequency in 28
graduate assertive issues related to situations arising in childhood.
The items are rated on a Likert scale ranging from 1 (never) to 5 (very
often), and the scores range from 5 to 25 for each type of ELS. The instrument also contains a subscale of minimization/denial to identify
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Martins et al.

individuals responding in a socially desirable manner. A cut point for

presence or absence of ELS was defined when one of these experiences, before the age of 18 years, reached at least a degree of moderate
or severe to extreme. This classification is proposed by major authors
in the area of childhood trauma (Bernstein et al., 1997, 1994, 2003; Carpenter et al., 2007). The version in Portuguese was translated and
adapted by Grassi-Oliveira et al. (2006).

Severity of Psychiatric Symptoms

To assess severity of psychiatric symptoms, we used instruments
commonly applied in the mental health research area.

Statistical Procedures
The comparison of parametric data between the two groups
(with ELS and without ELS) was performed using the Students ttests, when they presented normal distribution. We used the MannWhitneys U test for data without normal distribution. For nonparametric data analysis, as demographic and clinical characteristics, we applied the chi-square test. We also calculated the association between
ELS and psychiatric diagnoses with the chi-square test, using
Bonferronis correction when necessary. Correlations between ELS
and psychometric measures were examined using Pearsons correlation. All analyses were conducted using the Statistical Package for
the Social Sciences, SPSS for Windows, release 15.0. Significance
value was considered when p < 0.05.

Depression
To assess severity of depressive symptoms, the Beck Depression
Inventory (BDI) was applied (Beck et al., 1961), a self-report questionnaire with 21 items, in which a score of less than 9 points indicates no or
minimal depression; 10 to 18 points, mild-to-moderate depression; 19
to 29 points, moderate-to-severe depression; and greater than 30 points,
severe depression. The version in Portuguese was validated, translated,
and adapted by Cunha (2001).

Anxiety
To assess severity of anxiety symptoms, the Beck Anxiety Inventory (BAI) was applied (Beck et al., 1988), a self-report questionnaire
with 21 items, with an emphasis on physical symptoms. The version
in Portuguese was validated, translated, and adapted by Cunha (2001).

Anxiety-Depression
We also used the Hospital Anxiety and Depression Scale
(HADS; Zigmond and Snaith, 1983), a self-report questionnaire containing 14 items. The version in Portuguese was translated and adapted
by Botega et al. (1995).

Hopelessness
To assess severity of hopelessness symptoms, the Beck Hopelessness Scale (BHS) was applied (Beck et al., 1974), a self-report questionnaire with 20 true-false statements developed to assess the extent of
positive and negative beliefs about the future. The version in Portuguese
was translated and adapted by Cunha (2001).

Suicide Ideation
To assess severity of suicide ideation, the Beck Scale for Suicide
Ideation (BSI) was applied (Beck et al., 1979), a self-report questionnaire with 21 items, assessing the intensity of the patients specific attitudes, behaviors, and plans to commit suicide. Each item consists of
three options graded according to the intensity of the suicidality and
rated on a 3-point scale ranging from 0 to 2 points. The version in Portuguese was translated and adapted by Cunha (2001).

Impulsivity
To assess severity of impulsivity, the Barratt Impulsiveness Scale
(BIS-11) was applied (Patton et al., 1995), a self-report questionnaire
with 30 items. The literature suggests that a total score of 72 or greater
should be used to classify an individual as highly impulsive. The total
scores of the BIS-11 situated between 52 and 71 points should be considered within normal limits for impulsivity. Scores lower than 52
points are generally representative of individuals who are very controlled or who have not responded to the questionnaire honestly
(Stanford et al., 2009). The version in Portuguese was translated and
adapted by Diemen et al. (2007).
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RESULTS
Among the 81 patients assessed, we observed a predominance of
women (n = 59, 72.8%), Caucasians (n = 57, 70.4%), and people who
had completed high school (n = 29, 35.8%). The patients mean age was
37.62 (SD 1.21) years, with a minimum of 19 years and a maximum
of 65 years. Most (n = 41, 50.6%) were married, and a significant portion (n = 42, 51.9%) were living with spouses/partners. Furthermore,
86.5% of the patients reported religious practice and 77.0% had a family history of mental disorder.
In the assessed sample, 71.6% (n = 58) of the patients had some
type of severe ELS, compared with 28.4% (n = 23) who had no history
of ELS, according to the CTQ. Among 71.6% of the patients with ELS,
55.5% reported experiencing emotional abuse; 48.1%, physical neglect; 45.7%, emotional neglect; 39.5%, physical abuse; and 27.2%,
sexual abuse. We found that the emotional abuse subtype was the most
prevalent in ELS subtypes, according to the scale. Furthermore, most of
the sample (60.4%) reported experiencing three to five ELS categories.
However, we found that the patients with ELS did not differ from
the patients without ELS on demographic and clinical characteristics.
Furthermore, among patients sociodemographic and clinical characteristics, suicide attempt was the only variable we found that showed a statistically significant difference ( p = 0.02) between the groups. In
addition, among 81 subjects evaluated in the psychiatric sample, approximately 60% of the patients with ELS had a diagnosis of personality disorder, whereas in the group without ELS, 40% had a diagnosis of
personality disorder, resulting in a statistically significant difference between the groups (p = 0.032).
Table 1 describes sociodemographic and clinical characteristics
of the psychiatric patients according to ELS.
In the total sample, the distribution of psychiatric disorders was
as follows: more than 70% had a diagnosis of mood disorders, prevailing depressive disorders (n = 44, 54.3%), followed by bipolar disorder
(n = 17, 21.0%). The other diagnoses assessed were anxiety disorders
(n = 10, 12.3%), schizophrenia and other psychotic disorders (n = 5,
6.2%), eating disorders (n = 3, 3.7%), dissociative disorders (n = 1,
1.2%), as well as impulse control disorders not elsewhere classified
(n = 1, 1.2%). We did not include patients with diagnoses of substance
use disorder in the sample because the Day Hospital Unit does not admit patients with this diagnosis.
We conducted the analysis of association between ELS and all
psychiatric disorders. However, according to data presented in Table
2, there was no significant difference between the groups with and without ELS (2 = 8.44, df = 6.0, p = 0.188) in relation to the distribution of
psychiatric diagnoses.
In addition, we performed a second statistical analysis, comparing ELS subtypes with psychiatric disorders. Thus, significant association was found only between the emotional abuse subtype and
psychiatric diagnoses. Table 3 shows the results of the association between psychiatric disorders and emotional abuse.
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The Journal of Nervous and Mental Disease Volume 202, Number 11, November 2014

TABLE 1. Demographic and Clinical Features of Psychiatric

Patients With or Without ELS
N = 81 (100%)

Gender, n (%)
Female
Male
Age, mean SEM, yrs
Ethnicity, n (%)
Caucasian/white
Mulatto/mixed race
Black
Asian
Education, n (%), yrs
4
58
911
11
Marital status, n (%)
Never married
Married
Separated/divorced
Religious practice, n (%)
Employment status, n (%)
Employed
Unemployed
Smokers, n (%)
Alcoholic drinks user, n (%)
Illicit drug users, n (%)
Clinical disease, n (%)
Personality disorders, n (%)
Positive family history, n (%)
Suicide attempts in the past,
n (%)
CTQ total score, mean SEM
Emotional abuse
Physical abuse
Sexual abuse
Emotional neglect
Physical neglect

With ELS

Without ELS

58 (71.5)

23 (28.4)

44 (75.9)
14 (24.1)
37.98 1.37

15 (65.2)
8 (34.8)
36.73 2.52

40 (69.0)
12 (20.7)
5 (8.6)
1 (1.7)

17 (73.9)
5 (21.7)
1 (4.3)
0 (0)

11 (19.0)
9 (15.5)
23 (39.7)
15 (25.9)

3 (13.0)
2 (8.7)
10 (43.5)
8 (34.8)

18 (31.0)
30 (51.7)
10 (17.2)
43 (74.1)

10 (43.5)
11 (47.8)
2 (8.7)
21 (91.3)

8 (13.8)
50 (86.2)
14 (24.1)
14 (24.1)
3 (5.2)
26 (44.8)
33 (56.9)
42 (72.4)
43 (74.1)

4 (17.4)
19 (82.6)
6 (26.1)
2 (8.7)
0 (0)
8 (34.8)
7 (30.4)
15 (65.2)
11 (47.8)

66.05 2.47
16.7 0.68
11.96 0.80
9.25 0.84
16.32 0.68
11.79 0.53

34.78 0.84
8.26 0.40
5.60 0.22
5.04 0.04
9.43 0.59
6.43 0.31

p
NS

NS
NS

NS

NS

NS
NS

NS
NS
NS
NS
0.032*
NS
0.02*
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

NS indicates not significant.

*p < 0.05.

As observed, the results indicate a significant difference between

the groups with and without emotional abuse in relation to distribution
of psychiatric disorders (2 = 14.33, df = 6.0, p = 0.009). After applying
Bonferronis correction, we found a significant association between
emotional abuse and depressive disorders ( p < 0.05). Furthermore,
we found an association between absence of emotional abuse and the development of schizophrenia ( p < 0.05) in the patients. No significant differences were found between emotional abuse and other assessed
psychiatric diagnoses.
Next, we assessed the association between psychiatric disorders
and physical abuse, and we found that 32 patients (39.5%) had a history
of physical abuse in childhood and adolescence compared with 49 patients (60.5%) without physical abuse. Our data showed no significant
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Emotional Abuse and Depression

difference in distribution between psychiatric disorders, comparing the

groups with respect to physical abuse (2 = 8.14, df = 6.0, p = 0.200).
We found, among 81 assessed patients, an association between psychopathology and sexual abuse, in which 22 (27.2%) had a history of sexual abuse, compared with 59 patients (72.8%) without a history of
sexual abuse; however, according to the data presented, we could
not find a significant association between sexual abuse and psychiatric
disorders in adults (2 = 7.89, df = 6.0, p = 0.234). As for emotional
neglect, 37 patients were found to have a positive history (45.7%) compared with 44 patients (54.3%) without a history of emotional neglect.
We also found no significant differences between the groups regarding
distribution of psychiatric diagnoses and emotional neglect (2 = 7.40,
df = 6.0, p = 0.258). In the sample studied, 39 patients (48.1%) had a
history of physical neglect compared with 42 patients (51.9%) without
it. We did not find a significant association between physical neglect
and psychiatric disorders (2 = 5.37, df = 6.0, p = 0.541).

Severity of Psychiatric Symptoms

Regarding severity of psychiatric symptoms, the statistical analysis showed a significant difference between the groups of patients with
and without ELS. The patients with ELS showed more severe depressive symptoms than did the patients without ELS, according to their
scores in the BDI (t = 2.57, df = 41.12, p = 0.015) and in the depressive
subscale of the HADS (HAD-D; U = 397.5, p = 0.013). We also found a
trend for the patients with ELS to show higher scores of hopelessness,
according to the BHS (t = 1.96, df = 41.46, p = 0.055). However, we
found no significant differences between the groups regarding suicidal
ideation assessed by the BSI (U = 467.0, p = 0.163), regarding symptoms of anxiety assessed by the BAI (t = 1.40, df = 51.25, p =
0.206) and the anxiety subscale of the HADS (HAD-A; U = 490.0,
p = 0.143), or regarding symptoms of impulsivity assessed by the
BIS-11 (t = 1.69, df = 35.47, p = 0.073) (Table 4). We found three positive correlations between severity of ELS and psychiatric symptoms:
total score of hopelessness and total score of CTQ (BHS: r = 0.32,
p = 0.01), total score of suicidal ideation and total score of CTQ
(BSI: r = 0.32, p = 0.01), as well as total score of impulsivity and total
score of CTQ (BIS-11: r = 0.28, p = 0.03) (Table 4).
When investigating the influence of emotional abuse on severity
of psychiatric symptoms, we found significant differences between
the groups in all assessed psychiatric symptoms, shown in Table 5.
The patients with emotional abuse showed more severe depressive
symptoms in the BDI (t = 3.74, df = 77.0, p = 0.001) and in the
HAD-D (U = 520.0, p = 0.027), higher scores of hopelessness according to the BHS (U = 480.0, p = 0.002), as well as suicidal ideation
assessed by the BSI (U = 404.0, p = 0.001) than the patients without
TABLE 2. Distribution of Psychiatric Disorders Between Groups
N = 81 (100%)

All psychiatric disorders

Depressive disorders
Bipolar disorders
Schizophrenia and other
psychotic disorders
Anxiety disorders
Eating disorders
Dissociative disorders
Disorders of impulse control
not elsewhere classified

With ELS

Without ELS

58 (71.5)

23 (28.4)

34 (58.6)
13 (22.4)
2 (3.4)

10 (43.5)
4 (17.4)
3 (13.0)

7 (12.1)
1 (1.7)
1 (1.7)
0 (0)

3 (13.0)
2 (8.7)
0 (0)
1 (4.3)

p
0.188

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Martins et al.

TABLE 3. Association Between Emotional Abuse and Psychiatric Disorders

N = 81 (100%)
With Emotional Abuse,
45 (55.5%)

Without Emotional Abuse,

36 (44.4%)

31 (68.9)
8 (17.8)
0
4 (8.9)
1 (2.2)
1 (2.2)
0

13 (36.1)
9 (25.0)
5 (13.9)
6 (16.7)
2 (5.6)
0
1 (2.8)

0.009*
<0.05**
NS
<0.05**
NS
NS
NS
NS

All psychiatric disorders

Depressive disorders
Bipolar disorders
Schizophrenia and other psychotic disorders
Anxiety disorders
Eating disorders
Dissociative disorders
Disorders of impulse control not elsewhere classified
*p < 0.01; **p < 0.05.
NS indicates not significant.

emotional abuse. In addition, the patients with a history of emotional

abuse showed higher mean scores of anxiety in the BAI (t = 2.92,
df = 77.5, p = 0.004) and in the HAD-A (U = 450.0, p = 0.001) besides
greater impulsivity according to the BIS-11 (t = 2.25, df = 73.0, p =
0.026). These data are shown in Table 5.
Regarding the association between other ELS subtypes and severity of psychiatric symptoms, we found that the physical abuse subtype showed only a trend related to the symptom of hopelessness
assessed by the BHS (U = 589.0, p = 0.078). Relative to the sexual
abuse subtype, a significant difference was found between the groups
with and without ELS, only as to the influence of sexual abuse in severity of hopelessness, according to the BHS (U = 429.0, p = 0.037).
Moreover, the patients with emotional neglect had more severe depressive symptoms in the BDI (U = 518.0, p = 0.012) and in the HAD-D
(U = 520.0, p = 0.027) as well as higher scores of hopelessness according to the BHS (t = 2.96, df = 76.7, p = 0.004) than the patients without
emotional neglect. In addition, these patients had higher mean scores in
the BAI (t = 2.21, df = 70.8, p = 0.028) and the HAD-A (U = 519.0,
p = 0.027) as well as greater impulsivity according to the BIS-11 (t =
2.45, df = 78.0, p = 0.018) but did not differ for symptoms of suicidal
ideation according to the BSI (U = 607.0, p = 0.180).
Finally, relative to the influence of physical neglect on severity of
psychiatric symptoms, we found significant differences for symptoms
of depression in the BDI (t = 2.54, df = 76.4, p = 0.013) and in the
HAD-D (U = 539.0, p = 0.045) as well as for symptoms of hopelessness

in the BHS (U = 567.0, p = 0.025). We also found a tendency for the

patients with a past of physical negligence to have increased suicidal
ideation, according to the BSI (U = 565.0, p = 0.072), and increased impulsivity, when assessed by the BIS-11 (t = 1.98, df = 77.6, p = 0.053).
Regarding anxiety symptoms, we found no significant difference between the groups according to the BAI (t = 1.11, p = 0.264), but we
observed a tendency for the patients with physical neglect to present
more severe symptoms of anxiety than the patients without physical neglect in the HAD-A (U = 553.0, p = 0.061).

DISCUSSION
Our study showed the importance of this issue presented in Brazilian reality, as well as in several other countries, regarding the situation of ELS. Our results, obtained by assessing life history of adult
psychiatric patients, have shown an association between ELS and psychopathology in adults in more than 70% of the sample. These findings
corroborate several national and international studies, such as the study
conducted by Sar et al. (2004), who investigated five ELS subtypes and
found at least one psychiatric diagnosis associated with traumatic
events in childhood and adolescence in 89.5% of assessed patients.
Our patient sample consists of major depressive patients with a
history of ELS, presenting psychiatric comorbidity of personality disorders. These data corroborate evidence from the literature in the area of
child maltreatment, demonstrating the great importance of findings

TABLE 5. Severity of Psychiatric Symptoms Between the

Patients With and Without Emotional Abuse

TABLE 4. Severity of Psychiatric Symptoms Between the

Patients With and Without ELS

N = 81 (100%)

N = 81 (100%)
Scale
BDI
BAI
BHS
BSI
HAD-A
HAD-D
BIS-11

With ELS, 58 (71.5)

Without ELS, 23 (28.4)

33.73 1.59
31.54 1.96
12.01 0.71
13.66 1.37
13.24 0.63
13.92 0.64
77.80 1.41

26.36 2.37
27.13 2.44
9.43 1.10
9.88 2.23
12.0 0.93
10.73 1.11
72.73 2.63

0.015*
0.206
0.055
0.163
0.143
0.013*
0.073

Values are presented as mean standard error of the mean.

*p < 0.05.

778

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Scale
BDI
BAI
BHS
BSI
HAD-A
HAD-D
BIS-11

With Emotional
Abuse, 45.0 (55.5)

Without Emotional
Abuse, 36.0 (44.4)

35.9 1.72
34.15 2.26
12.95 0.77
16.16 1.49
14.23 0.65
14.21 0.69
78.90 1.63

26.3 1.87
25.52 1.89
9.22 0.86
8.11 1.59
11.22 0.77
11.48 0.91
73.22 1.91

0.001*
0.004**
0.002**
0.001*
0.001*
0.027***
0.026***

Values are presented as mean standard error of the mean.

*p < 0.001; **p < 0.01; ***p < 0.05.

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The Journal of Nervous and Mental Disease Volume 202, Number 11, November 2014

regarding the association between ELS subtypes and diagnosis of personality disorders. Researchers have shown associations between personal stories of abuse in childhood and personality disorders in
adulthood, and ELS has been shown to be a predictor of personality disorders (Bandelow et al., 2005; Bradley et al., 2005; Giese et al., 1998;
Grover et al., 2007).
Another interesting point identified in this study was the association between emotional abuse and depressive disorders. Our findings
indicate that approximately 70% of patients diagnosed with depressive
disorder had experienced emotional abuse in childhood and adolescence. These results are consistent with other studies that demonstrate this association (Briere and Runtz, 1988; Gibb et al., 2003,
2007; Mullen et al., 1996; Wingenfeld et al., 2011). Thus, it is evident
that the association between emotional abuse and depression in adults is
extremely relevant, both in research and clinical contexts. Emotional
abuse is evidenced by damaging the emotional competence of children
and adolescents (ability of loving others and feeling good about themselves); it consists of acts of humiliation, degradation, rejection, isolation, terrorism, corruption, lettering, threats, verbal abuse, and denial
of affection (De Antoni, 2012; De Antoni and Koller, 2012). Mayer
and Koller (2012) report that emotional abuse is present in all forms
of violence, although it can occur singly, and ranges from overt inattention to total rejection. Among ELS subtypes, emotional abuse has been
indicated by international researchers as one of the most severe forms,
and it is associated with a spectrum of disabling psychiatric disorders in
adults (Bremmer et al., 1999; Hart and Brassard, 1987). This subtype is
difficult to identify because of its invisibility. Accurate observation by
family members and professionals involved in taking care of vulnerable children and adolescents is required (De Antoni, 2012). In
addition, consensus in the literature emphasizes the modulatory role
of childhood emotional abuse among depressed patients because they
had worse prognosis, with relapse of depression within the period of
12 months (Forman et al., 2004; Johnstone et al., 2009; Kaplan and
Klinetob, 2000; Liu et al., 2009; Miniati et al., 2010).
In relation to depression, it is characterized by symptoms of a severe, chronic, and recurrent course, with high levels of functional disability and impaired physical health. Among the factors associated
with depression in adulthood, there is the exposure to stressors in childhood, such as abuse, neglect, and death of parents or substitutes; maternal or paternal deprivation by abandonment; and separation or divorce.
Approximately 60% of cases of depressive episodes are preceded by the
occurrence of stressors, especially of psychosocial origin, so the known
influence of genetic factors in the development of depression could be
due to an increased sensitivity to stressful events (Baes et al., 2012;
Mello et al., 2009; Tofoli et al., 2011). The literature emphasizes that
depression is a relatively common condition, with a chronic and recurrent course, often related to functional disability and impaired physical
health (Fleck et al., 2009) as well as lifelong duration, affecting approximately 10% to 25% of women and 5% to 12% of men (Branco et al.,
2009; Fleck et al., 2003; Kessler et al., 2005; Pereira and Lovisi,
2008; Saloma et al., 2009). Moreover, depressed patients use health services more frequently and have a poor prognosis when there is a report
of ELS. According to the WHO, depression is a public worldwide
health problem, a leader among the leading causes of years of life lived
with a disability, with high rates of morbidity and mortality, which affects approximately 340 million people, and there are projections that,
by 2020, it will be the second leading cause of overall damage calculated at all ages and in both sexes. It corresponds to 70% of suicides that
occur in the world, being the leading cause of death in young people
aged between 15 and 44 years (Nemeroff, 2008; Razzouk et al.,
2009; Zavaschi et al., 2002). In this sense, the relevance of the investigation of ELS in depressive patients becomes evident when we analyze
its consequences based on sensitization of brain pathways involved
with depression (Juruena, 2013; Lipp et al., 2009; Mello et al., 2007;
Saloma et al., 2009).
2014 Lippincott Williams & Wilkins

Emotional Abuse and Depression

Although we could not find a positive association between other

ELS subtypes (physical abuse, sexual abuse, emotional neglect, physical neglect) and psychiatric disorders, our results point toward a positive association between severity of ELS in psychiatric patients and
severity of psychiatric symptoms. Our results are consistent with the
scientific evidence regarding magnitude of ELS being associated with
severity of psychiatric disorders and are compatible with a methodologically similar study, conducted by Roy (2002), that demonstrated a positive association between severe stories of ELS in psychiatric patients
and the severity of their psychiatric symptoms.
Moreover, Schoedl and Campanini (2011) express concern that
emotional and psychological problems caused by experiences of ELS
subtypes may be factors that bring and increase the risks and consequences of individuals mental health. Similarities between the three
forms of abuse in terms of their association with negative adult outcomes were more apparent than any differences, although there was a
trend for sexual abuse to be particularly associated with sexual problems; emotional abuse, with low self-esteem; and physical abuse, with
marital breakdown.
Several limitations of the current study should be considered.
The first limitation is related to the exclusion of patients with substance
abuse disorder because of the fact that the Day Hospital Unit of the
General Clinical Hospital does not admit patients with such psychopathology. These data should be interpreted carefully because this is a limitation of the present study and several data and studies have shown
significant associations between ELS and diagnosis of substance abuse
disorder in adults (Bulik et al., 2001; Duncan et al., 2008; Khoury et al.,
2010). The second limitation is related to ELS data collection being retrospective, with a possible influence on the reliability of the responses.
However, many studies have suggested that evaluation of specific forms
of ELS is more reliable than global assessments (Brewin et al., 1993).
Furthermore, we used the CTQ, a well-validated and reliable measure
of childhood trauma.

CONCLUSIONS
Our findings indicate that psychiatric disorders are associated
with ELS, whose subtypes should be considered a public health problem. Furthermore, we emphasize the importance of preventive practices
in the mental health area and the need for developing further studies to
elucidate the importance of emotional abuse as a risk factor of severe
and disabling psychopathology, such as depression. However, one must
consider that not all people exposed ELS will develop psychiatric disorders. A fundamental understanding of individual differences in vulnerability and resilience to pathogenic effects of stress is necessary.
ACKNOWLEDGMENT
The authors thank Fabio Camacho, who helped with grammar and
English style corrections.
DISCLOSURES
This study was supported by the FAPESP, the FAEPA, the CNPq,
and the CAPES.
The authors declare no conflict of interest.
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